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Abstract

Background

Many people now seek alternative methods of weight loss. The internet provides a readily
available source of weight reduction products, the ingredients of which are often
unclear. The authors describe a case of acute hepatitis in a 20 year old woman caused
by such a product purchased over the internet.

Case Presentation

A 20-year old woman presented with a two day history of abdominal pain, vomiting and
jaundice. There were no identifiable risk factors for chronic liver disease. Liver
function tests demonstrated an acute hepatitis (aminoaspartate transaminase 1230 IU/L).
A chronic liver disease screen was negative. The patient had started a weight loss
product (Pro-Lean), purchased over the internet two weeks prior to presentation. The patient was treated
conservatively, and improved. The sequence of events suggests an acute hepatitis caused
by an herbal weight loss product.

Conclusion

This case report highlights the dangers of weight loss products available to the public
over the internet, and the importance of asking specifically about alternative medicines
in patients who present with an acute hepatitis.

Background

Obesity is increasingly recognised as a medical problem [1]. Many people now seek alternative methods of weight loss, in particular weight reduction
products, some of which are available over the internet. The potential dangers of
these products are often not known. The authors describe a case of acute hepatitis
in a 20 year old woman caused by such a product purchased over the internet.

Case Presentation

A 20-year-old woman presented with a two-day history of right upper quadrant pain,
vomiting and jaundice. She did not drink alcohol and her only regular medication was
the oral contraceptive pill that she had taken for many years. There was no history
of recent foreign travel. There had also been no recent use of paracetamol, non steroidal
anti-inflammatory drugs (NSAIDs), anti-biotics, or recreational drugs. She denied
the use of intravenous drugs. On examination, she was icteric, with epigastric tenderness
but no palpable organomegaly. There was no hepatic encephalopathy, nor stigmata of
chronic liver disease. The full blood count was normal; white cell count 7.4 109/L (NR 4–11), platelets 200 109/L (NR 150–400), haemoglobin 15.9 g/dl (NR 11–13). Urea and electrolytes and coagulation
studies were also normal. Liver functions tests (LFTs) were abnormal; bilirubin 53
μmol/L (1–19), alkaline phosphatase 92 IU/L (ALP 25–100), aspartate aminotransaminase
1230 IU/L (AST 7–40), albumin 40 g/L (36–52), and international normalised ratio 1.1
(INR 0.8–1.3). Hepatitis A IgM (HAV IgM), hepatitis B surface antigen (HBsAg) and
hepatitis C antibody (HCV Ab) were negative. Herpes simplex virus, Epstein Barr virus
and cytomegalovirus were all undetectable. Auto-immune antibody serology, serum copper,
caeruloplasmin, and ferritin were normal. Hepato-biliary ultrasonography was normal.
On further questioning, the patient volunteered that she had started a weight-loss
product called, Pro-lean, two weeks before admission. This had been purchased over
the internet. Pro-lean was stopped, and the LFTs started to improve. On discharge
(5 days later) her LFTs continued to improve (see Table 1). A liver biopsy was not performed, because of the rapid biochemical improvement.
At two-months from the initial presentation the LFTs had normalised (Table 1), and the patient remained well. Repeat virology (HAV IgM, HBsAg and HCV Ab), in
the convalescent stage remained negative.

Discussion

Two-thirds of adults over 45 years are now classified as being obese. Obesity was
estimated to have cost the NHS £500,000,000 in 1998. As levels have risen, so to have
the number of diets and treatments alternative to the traditional methods of weight
loss.

Pro-Lean, by Pro-image is a weight loss product containing herbs, botanicals and chromium.
One capsule (to be taken once per day) contains 150 μg of chromium (chromium dinicotinate
glycinate), 12–15 μg of vitamin B12, 50 μg of vanadium, caffeine 200 mg, 150 μg of
cyperus root extract and 50 μg of L-tyrosine. Furthermore, other ingredients include
ma-huang, guarana, kola nut, white willow bark, ginkgo biloba, bladderwrack, gotu
kola, boron, ginseng, fo-ti, magnesium salicylate, folic acid, bee pollen, spirulina
and ginger root. Chromium toxicity has been linked with cases of hepatic, renal and
cardiac failure, as well as bronchial malignancy [2]. The daily requirement is 5 to 115 μg/day. Chromium-induced toxic hepatitis has previously
been described, in a 35-year old woman who had been taking a chromium dietary product
(200 μg/day) for five months [3]. However, it is often difficult to determine which component of these products is
responsible for hepato-toxicity as there are often many pharmacologically active constituents.
Many herbal products have been implicated in liver toxicity including kava, chapparal,
germander, comfrey roots [4], and also ma huang [5]. Orthotopic liver transplantation has been required in some cases of drug induced
hepatitis caused by herbal remedies observed [6]. In the United Kingdom health products are treated as food if they are not granted
a medical license. No health claims can be made on the labelling. In the United States
food, and drug administration (FDA) approval is only needed for medicines. Herbal
products do not fall into this category and are viewed as dietary supplements. Patients
may regard these products as healthy alternatives and may be unaware of their side
effects, and contents. An analysis of 260 Asian patent medicines studied by the Californian
health services, food and drug branch found that 32% of the analysed samples contained
undeclared pharmaceuticals and heavy metals [7].

On discontinuation of Pro-Lean the patient improved both clinically and bio-chemically,
suggesting causality. The clinical diagnostic scale (CDS) is a useful screening tool
which has been developed for the diagnosis of drug induced liver injury [8]. The CDS score in this case was 12. A CDS score of >9 is assumed to be drug related
unless an alternative diagnosis is suspected. It is difficult to ascribe the observed
hepatic toxicity to one specific ingredient alone contained within Pro-Lean. Chromium
toxicity would be less likely given the normal renal function. The clinical presentation
and pattern of hepatic toxicity in this case is very similar to the case described
by Nadir et al (1996), suggesting ma huang may have played an active role.

Conclusion

This case highlights the importance of inquiring into alternative medicines, herbal
remedies and unconventional diets in cases of acute hepatitis, where the cause is
uncertain. It also raises questions regarding the regulation, licensing and safety
of herbal and alternative health products that can be bought over the internet.